Background: One of the most common causes of morbidity caused during adhesiolysis is inadvertent enterotomy. It is important to have awareness about the adhesiolysis-related morbidity to properly inform the patients of the risks before surgery, for surgeons to take these risks into consideration while making operative decisions, and to get better at the diagnosis of post-operative complications.Patients and Methods: We did a prospective observational study on 55 patients who underwent laparotomy for adhesiolysis at the J.L.N. Medical College, Ajmer. Study period was 24 months, from January 2015 to January 2017, including a follow-up period of 6 months. Our primary aim was to do a detailed assessment and analysis of adhesiolysis and to assess the post-operative complications related to adhesiolysis.Results: The incidence of full thickness bowel defects was 9 (16.36%). Bowel resection and anastomosis were required in five operations (55.56%). The severity of adhesions and adhesiolysis time was more with patients with two or more previous laparotomies, mean 132 ± 40.27 min. Re-admission rates were also much higher in patients who had enterotomy.Conclusion: This study has demonstrated the substantial clinical burden of adhesiolysis, particularly when a bowel defect occurs.

Adhesions can be taken as a scar tissue that connects the internal organs not normally connected.[1] As a result of injury they are formed between tissues. During the healing process there is deposition of fibrin onto injured tissue. This fibrin seals the injury and builds– flimsy adhesions. These initial adhesions are limited by fibrinolytic substances which are activated by tissue plasminogen activator, which activates plasminogen into plasmin that splits these fibrin bands. When the production or action of these fibrinolytic substances is decreased during inflammation by release of plasminogen activator inhibitor which inhibits tissue plasminogen activator, these adhesions persevere.[2] Later collagen is laid down by fibroblasts and macrophages leading to formation of permanent adhesions. More than 90% of abdominal surgeries result in formation of peritoneal adhesions.[3],[4] Peritoneal mesothelium is the largest serous membrane of the body and is only single cell thick. Abdominal surgery injures this peritoneum. There are multiple hypotheses on the origin of colonizing cells which will cover this peritoneal defect, which includes growth from peripheral cells, transformation of the underlying mesenchymal cells, transplantation of mesothelial cells from adjacent structures or free-floating mesenchymal cells, and transformation of cells from peripheral fluid.[2] Intra-abdominal adhesions can be caused by acute inflammation as seen in case of sites of bowel anastomosis, re-peritonealization of raw area, trauma, and ischemia. It can also be caused by foreign materials like starch, talc, gauze, and silk. Peritonitis and tuberculosis are also well known to cause adhesion in our country. Crohn's disease and radiation enteritis are more common in western part of the world.[5] Adhesions frequently cause abdominal pain, intestinal obstruction, and female infertility.[3],[4],[6],[7],[8],[9] Complications that occur due to adhesion-related repeat surgeries lead to even higher morbidity. One of the most common causes of morbidity caused during adhesiolysis is inadvertent enterotomy, which has been reported to be as high as 19%.[10] It is defined as a full thickness bowel defect caused involuntarily at the time of surgery. It is important to have awareness of the adhesiolysis-related morbidity to properly inform the patients of the risks before surgery, for surgeons to take these risks into consideration while making operative decisions, and to get better at the diagnosis of post-operative complications.

Patients and Methods

We did a prospective observational study on 55 patients who underwent laparotomy for adhesiolysis at the J.L.N. Medical College, Ajmer. Study period was 24 months, from January 2015 to January 2017, including a follow-up period of 6 months. Our primary aim was to do a detailed assessment and analysis of adhesiolysis and to assess post-operative complications related to adhesiolysis. Patients below the age of 18 years and those with mental illnesses were excluded from the study. Relevant surgical and medical data were collected and assessed before, during, and after the hospital stay for a period of 6 months. During surgery, detailed information of adhesions, adhesiolysis, and inadvertent enterotomy were collected through direct observation by a trained researcher. The adhesions were examined macroscopically by the Zühlke Macroscopic Classification grading system [Table 1]. Primary outcomes were incidence of adhesions, adhesiolysis time measured in minutes starting from the time adhesiolysis started till when the area was made adhesion free, and post-operative complications noted are wound infection, anastomotic leak, fistula formation, pneumonia, sepsis, urinary tract infection (UTI), and death. Secondary outcomes were other morbidities including hospital stay, intensive care unit (ICU) stay, parenteral feeding, abdominal drain duration, Ryle's tube in situ duration, incidence of emergency re-operations, and incidence of re-admission in hospital within 30 days after discharge. Univariate comparisons were performed using linear regression for continuous and logistic regression for dichotomous data. Effect size was expressed as mean difference with standard deviation for continuous data. To avoid potential bias by an unequal distribution of risk factors, we calculated an adjusted effect size using multivariate linear and logistic regression for continuous and dichotomous data, respectively. All factors with unequal distribution at baseline with P < 0.010 were included in the multivariate model, except a history of peritoneal surgery and generalized peritonitis, and peritoneal surgery and previous peritonitis are considered pathogenic for adhesion formation and were not expected to have further independent adverse effects on treatment outcomes. All outcomes were assessed per operation and analyzed according to an intention-to-treat, unless otherwise stated.

In our study, maximum number of patients belonged to the age group of 50 years and above. One patient was in the 30–40 years group and 25 patients in the 41–50 years group. The mean age of the study population was 53.07 years. There were 33 males (60%) and 22 females (40%) with male-to-female ratio of 3:2. The body mass index (BMI) distribution with most (60%) of the patients (33 patients) belonging to the BMI group of 25–30. Followed by 20 patients (36.36%) in the 20–25 group and 2 patients (3.64%) with BMI of ≥30. The mean BMI was found to be 25.7. Out of 55 patients, 12 (21.82%) were smokers, 17 (30.91%) were non-smokers, and 26 (47.27%) were ex-smokers, while the history of alcohol abuse in the study population was present in 17 (31.48%) patients, 22 (40.74%) were non-alcoholic, and 16 (24.63%) were ex-alcoholic. The most common etiology for the presence of adhesions was found to be a history of previous intra-abdominal surgery present in 46 (83.64%) of patients as compared to 9 (16.36%) with no history of previous laparotomy. History of peritonitis was also found in most of the patients with adhesions i.e., 44 out of 55 cases (80%) as compared to 11 patients (20%) with no previous history of peritonitis. The mean adhesiolysis time in our study was 125.63 ± 36.23 min. The severity of adhesions and adhesiolysis time was more with patients with two or more previous laparotomies with a mean of 132 ± 40.27 min. Our study showed that the most common site of adhesion was in the lower abdomen (below umbilicus) with 28 patients (50.91%) having adhesions in the lower abdomen and pelvis. Followed by adhesions with the abdominal wall in a previous laparotomy scar with 24 patients (43.64%) and least common site of adhesion was the upper abdomen with only 3 patients (5.45%) having adhesions above the level of umbilicus. The median Zühlke score at all these anatomical sites was 2. Patients who have adhesions and no prior surgery or general peritonitis in their history usually only had a few low-grade adhesions. The incidence of full thickness bowel defects was 9 (16.36%). Bowel resection and anastomosis were required in five operations (55.56%) with one or more enterotomies, and in the remaining operations, enterotomies were repaired by primary suturing. Out of 15 patients who had a history of previous single laparotomy, enterotomy occurred in only 1 patient (6.67%), out of 22 patients who had previous two laparotomies enterotomy occurred in 4 patients (18.18%), out of 5 patients who had three previous laparotomies enterotomy occurred in 2 patients (40.00%), and maximum enterotomies occurred in patients with a history of four or more prior surgeries, 2 out of 4 patients (50%) had enterotomy. Our study also showed that a high Zühlke score correlated with an increased incidence of enterotomy. Incidence of enterotomy was 0% in 19 patients with Grade 1 Zühlke score, out of 20 patients with Zühlke Grade 2 enterotomy occurred in 1 patient (5%). Out of 8 patients with Zühlke Grade 3 enterotomy occurred in 3 patients (37.50%), and out of 8 patients with Zühlke Grade 4 enterotomy occurred in 5 patients (62.50%) [Table 2]. In patients where enterotomy occurred the hospital stay was more with mean of 19.87 ± 2.23 days as compared to 11.80 ± 2.57 (P < 0.0001). The ICU stay was lengthened with an average ICU stay of 3.50 ± 1.07 days (P < 0.0001) in patients in which enterotomy occurred as compared to the mean ICU stay of 0.65 ± 0.82 (P < 0.0001). Ryle's tube drainage was done for longer time in patients with enterotomy 6.11 ± 2.26 days (P < 0.0001), while in patients with no enterotomy it was kept for shorter duration. Abdominal drain was kept for an average of 9.44 ± 1.94 days (P < 0.0001) in patients with enterotomy which was longer as compared to those in which no enterotomy occurred [Table 3]. About 4 out of 9 (44.44%) patients with enterotomy suffered with sepsis which was characterized by a total leukocyte count of >12,000/mm3 or <4,000/mm3, temperature of >38°C (100.4°F), and a positive blood culture. None of the patients without enterotomy suffered from sepsis. Wound infection took place in 3 out of 9 (33.33%) patients of enterotomy which was much higher than those without any enterotomy i.e., 2 out of 46 (4.34%). Fecal fistula developed in a single case of enterotomy and in none of the cases with no enterotomy. Anastomotic leak took place in only one case of the five resections and anastomosis done for enterotomy. Post-operative UTI took place in three cases all of which were patients who were catheterized for longer durations.

Re-admission within 30 days after discharge was also of much higher rate in the patients who had enterotomy, 4 out of 9 (44.44%) patients were re-admitted with a complaint related to bowel obstruction. About 2 out of 9 patients (22.22%) with enterotomy died due to complications related to sepsis. While 1 out of 46 (2.17%) patients in the non-enterotomy group died due to cardiac cause [Table 4].

This prospective observational study guaranteed data accuracy by direct observation of complications related to adhesiolysis. Before this, earlier studies relied on medical records, which often proved to be inaccurate.[11–13] In our study, adhesiolysis-related morbidity especially related to enterotomy was high and resulted in more surgical site infection, post-operative sepsis, longer hospital stay, and more re-admissions. Zülhke classification has been shown useful and practicable for the objective examination and evaluation of re-laparotomies in connection with expert opinion reports and animal experiments on adhesion research [Table 1].[14] Highly dense adhesions are more susceptible to cause inadvertent enterotomy during adhesiolysis. Adhesiolysis time comprehends firmness and quantity of adhesions and is a better consideration for the complexity of adhesiolysis. The incidence of enterotomy in our study was 16.36%, which was related to a significantly higher morbidity, this correlates with other retrospective studies.[10],[15] Surgical site infection was the most prominent complication which was related to longer adhesiolysis time. Previously two studies have shown that the number of previous laparotomies increases the risk of bowel injury during adhesiolysis.[10],[11] In another large randomized prospective study of patients undergoing colorectal resection for benign disease, for every 30 min of adhesiolysis there was an increase in post-operative stay by 1 day,[16] which correlates with our study. Enterotomy increases the risk for unplanned enterotomy, wound infection, re-operations, and fistula formation. After any type of abdominal surgery, a repeat laparotomy is related to higher incidence of enterotomy leading to higher rates of need for parenteral feeding, longer duration of abdominal drains, and longer duration of Ryle's tube drainage, which was also the finding of a prospective study in which surgical procedures with and without adhesiolysis were compared on the incidence of inadvertent bowel defects. In 10.5% patients undergoing adhesiolysis bowel defect occurred, compared with 0% in those not undergoing adhesiolysis (P < 0.001). Adhesiolysis was associated with an increase incidence of sepsis, increase in incidence of intra-abdominal complications and wound infection, longer hospital stay, and higher hospital costs. Mortality after a bowel defect was 8% and after uncomplicated adhesiolysis it was 1.6%. In their study, morbidity due to adhesiolysis was also high: a median of 20 min increase of operative time and 1 in 10 risk of enterotomy.[17] Recently a non-invasive technique is being developed to diagnose abdominal adhesions pre-operatively. In this technique, the smooth movement of the abdominal content against abdominal wall during respiration is imaged using sagittal dynamic magnetic resonance technique. The results of this technique are promising but are still in its preliminary phase.[18] India is a country of limited resources with majority of the population belonging to the rural areas and a low per capita income. The cost burden of the adhesions is of great significance in our part of the world. Cost effectiveness analyses that are currently available have focused on prevention of adhesive small bowel obstruction and have not lead to the routine use of anti-adhesive barriers.[19] With the projected increase in more repeat abdominal surgeries because of a longer life expectancy and newer technologies, prevention of adhesiolysis-related morbidity might be even more cost effective.

Conclusion

This study has demonstrated the substantial clinical burden of adhesiolysis, particularly when a bowel defect occurs. All surgeons treating patients with disorders of the abdominal cavity that might require surgery should be aware of the adverse effects of adhesiolysis. This data can be of help when counseling patients before surgery, when surgeons and health care providers make decisions on implementing anti-adhesive strategies.